disappointed

Ted.E.Palen at KP.ORG Ted.E.Palen at KP.ORG
Mon Sep 28 16:04:53 UTC 2015


I do think everyone learns that ACE-I have cough as a possible side 
effect.  But that does not mean that it recognized during the course of an 
evaluation of someone with a cough.
First, the medication list needs to be update in the EMR, or you need to 
get an accurate medication list from the patient.  Neither of these always 
happens.
Second, if you recognize that ACE-I may be the cause of the cough, then 
you need to do a trial off the ACE-I.  That means you and the patient need 
to agree to allowing the blood pressure to rise during this trial period.
Then if the cough goes away, you need to decide on a new blood pressure 
medication treatment plan. This involves starting a new medication, 
monitor blood pressure, and possibly titrating the dose.
Lots of steps, follow-up, call backs, monitoring, etc. that some may not 
be willing to embark on.  Especially if the patient patient is seeking 
care for their cough in an urgent care environment without someone willing 
to take on this responsibility.
 


Ted E. Palen, PhD MD, MSPH | Physician Investigator | Institute for Health 
Research | Kaiser Permanente Colorado
Physician Manager for Clinical Reporting | Medical Cost Management| 
Colorado Permanente Medical Group
( 303-614-1215 | 7 303-614-1305 | Tie line: 8-625-1215 | * 
ted.e.palen at kp.org
Administrative Assistant: Akia A. Lynch: ( 303-614-1322 | * 
akia.a.lynch at kp.org

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From:   Joe Graedon <jgraedon at GMAIL.COM>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   09/28/2015 04:45 AM
Subject:        Re: [IMPROVEDX] disappointed



Here is a question Ted…speaking of coughs…

Our website has become a magnet for individuals who have been misdiagnosed 
because of an ACEi cough. We have heard from hundreds of people who have 
been worked up for allergies, asthma and goodness knows what else even 
though they were on a drug like lisinopril and complained of a persistent, 
uncontrollable cough. 

My questions are: 1) does any medical student NOT learn that ACE 
inhibitors cause cough and 2) why is this such a hard thing to diagnose? 

Here are just a few links so you can see for yourself:

Can ACE Inhibitors Cause Constant Coughing?
http://www.peoplespharmacy.com/2007/10/05/can-ace-inhibit/

Ace Inhibitor Blood Pressure Pill Causes Cough
http://www.peoplespharmacy.com/2009/02/13/ace-inhibitor-b/

When Will Doctors Pay Attention to an ACE Cough?
http://www.peoplespharmacy.com/2010/04/26/when-will-doctors-pay-attention-to-an-ace-cough/

Blood Pressure Meds Lead to All-Night Coughing
http://www.peoplespharmacy.com/2007/12/12/blood-pressure-1/

Pill Triggered Cough from Hell
http://www.peoplespharmacy.com/2010/04/05/pill-triggered-cough-from-hell/

Why Do So Many Doctors Ignore Obvious Drug Side Effects?
http://www.peoplespharmacy.com/2015/05/14/why-do-so-many-doctors-ignore-obvious-drug-side-effects/


This is just a small sampling or articles on our website.

Joe Graedon




On Sep 26, 2015, at 11:20 PM, Ted.E.Palen at KP.ORG wrote:

I often list a general diagnosis if I am unsure of a specific diagnosis. 
Such as, cough, instead of viral bronchitis, or knee pain instead of 
collateral ligament strain, if I am not sure of the more specific 
diagnosis. 

Ted E. Palen, PhD, MD, MSPH
Physician Manager Clinical Reporting 
Utilization Management
Institute of Health Research
Colorado Permanente Medical Group
10065 E Harvard Ave, Suite 300
Denver CO  80231

Phone: 303-614-1215
Fax: 303-614-1305
email: ted.e.palen at kp.org

On Sep 26, 2015, at 8:50 AM, "Charlie Garland - The Innovation Outlet" <
cgarland at INNOVATIONOUTLET.BIZ> wrote:

Mark, you (and others here) bring up an outstanding point.  Imagine for a 
minute what would happen if the EMR screen suddenly had a data entry field 
for a "degree of certainty" value (percentage) next to the ICD code. Would 
this not compel the physician to think just a bit more carefully -- at 
that very moment -- about just how confident he/she is about the Dx?  And, 
wouldn't that then (some portion of the time) trigger the contemplation of 
at least one alternative DDx?

Now, imagine that "confidence field" being gone (which it is).  Isn't the 
implicit assumption here that the diagnostician is 100% confident of 
his/her diagnosis?  Whether or not this is how anyone might intend or 
infer the EMR data, in some cases, that is the way it's regarded. 
Considering what Brian Jackson mentioned, in some portion of cases, there 
is clearly a degree of uncertainty that is in the mix.  And that data 
value -- regardless of how accurately it can be captured -- is something 
that seems likely to improve the prospects of patient safety, over the 
long haul at least.

It would be an interesting research study to see what would happen if an 
institution's EMR system explicitly offered an additional field or two 
(confidence interval, most likely DDx, etc.).  How would physicians 
respond to this, over time?  What might be the implications of that 
additional data -- and the "forcing strategy" effect it would possibly 
have on diagnosticians (and others accessing the same data) -- upon Dx 
error rates?

Just one opinion.

=================================================
 
Charlie Garland, President

The Innovation Outlet
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-------- Original Message --------
Subject: Re: [IMPROVEDX] disappointed
From: Mark Graber <graber.mark at GMAIL.COM>
Date: Thu, September 24, 2015 8:12 pm
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

I'm seconding Brian Jackson's suggestion to move towards attaching levels 
of certainty to each diagnosis.  I'm especially fond of the "NYD" label 
Sam Campbell had on his list of the 10 best things to have happened in the 
field of emergency medicine in Canada.   NYD = not yet diagnoses.  This 
would alert the next person in the chain to keep thinking !   If we only 
had an ICD-10 code for that …..

On Sep 24, 2015, at 10:32 AM, Jackson, Brian <brian.jackson at aruplab.com> 
wrote:

We might want to be careful about this one.  From a research perspective, 
analyzing time to diagnosis would indeed be interesting and productive. 
But if in the process we give regulators, payors and attorneys new ways to 
punish delays at an individual physician level, it could amplify premature 
closure and overdiagnosis.
 
A suggestion others have brought up, and I suspect this needs to be pushed 
more aggressively, is the concept of explicitly labeling diagnoses with 
their level of certainty, e.g. as tentative or working diagnoses where 
appropriate.  Sometimes empiric therapy is the best way to proceed.  When 
empiric therapy fails, it doesn’t necessarily mean the diagnostic process 
failed, i.e. that a diagnostic error occurred.
 
Many of the complications introduced by both medicolegal and quality 
improvement efforts come from treating diagnosis as a black and white 
situation.  As much as I like the current news coverage of the IOM report, 
it’s reinforcing that black/white perspective.
 
--Brian Jackson
 
From: robert bell [
mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG] 
Sent: Wednesday, September 23, 2015 3:25 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] disappointed
 
But our foot is in the door. 
 
Also, as we get more information on Time to Diagnosis, it would seem that 
there could be a kind of “standard time to diagnosis,” for less common 
diseases/conditions that could be adjusted from time to time as we get 
more proficient (e.g. for myasthenia gravis), perhaps even adjusted in 
some way for the medical sophistication of the medical center in question!
 
Do we need to talk about standards for what is a delayed diagnosis?  Or 
maybe that has already been discussed.
 
Just publishing a list of the common conditions we THINK are diseases of 
delayed diagnosis would be a start.
 
Rob Bell, M.D.
 
 
On Sep 23, 2015, at 11:19 AM, Michael Grossman <Michael.Grossman at MIHS.ORG> 
wrote:
 
I agree with your assessment. The IOM sometimes seems to fall short of 
expectations. Their relatively recent report on Graduate Medical Education 
was disappointing. 
The fact that multiple news agencies are running with this story may lead 
to some misunderstandings , especially on the nature of "delayed 
diagnoses".
Michael Grossman, MD MACP

-----Original Message-----
From: Robert L Wears, MD, MS, PhD [mailto:wears at UFL.EDU] 
Sent: Wednesday, September 23, 2015 9:31 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] disappointed

Great that misdiagnosis and related failures are getting attention, but 
...

This is a disappointing effort; a naïve, keyhole view of a complex 
problem.

I count 82 mentions of 'error' in the first 15 pages (~5.5 per page), 753 
in the entire document.

Lots of discussion about biases (78 mentions) but important issues that 
challenge the focus on 'error', such as hindsight bias, or outcome bias, 
are never mentioned even once.

This restriction to a very narrow framing of the problem is unlikely to 
lead to progress.

bob



Robert L Wears, MD, MS, PhD
University of Florida              Imperial College London
wears at ufl.edu                        r.wears at imperial.ac.uk
1-904-244-4405 (ass't)            +44 (0)791 015 2219
Nothing matters very much, and very few things matter at all.
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